Out of the Shadows celebrates the hard work of third world activists who have dedicated their lives to bringing mental health care to their countries. It presents a striking contrast to the neglect and abuse the mentally ill experience in the US.

Globally half a billion people suffer from mental disorders, such as depression, bipolar illness and schizophrenia – more than all AIDS, malaria and TB cases combined. Yet owing to profound stigma, publicly funded mental health services are virtually non-existent in many third world countries. India, for example, spends less than 1% of their health budget on mental health. And in Togo, mentally ill men and women are chained to trees.

Why Hasn’t The Family Of Va. Man Who Starved Himself Been Told The Facts? Nearly 7 Months After Jamycheal Mitchell’s Death Still No Reports

Why haven’t two state agencies investigating the death of Jamycheal Mitchell, a 24 year-old Virginia man diagnosed with bipolar disorder who was found dead in his jail cell August 19, 2015, released the results of their investigations?

THANK YOU FOR THIS VERY IMPORTANT LESSON!

(3-22-16) An Eastern State Hospital employee was “astonished and distraught” when she opened a desk drawer last August and discovered that a Virginia judge had ordered Jamycheal Mitchell to be sent from a Portsmouth jail to the mental hospital to be evaluated.

The judge’s order had been issued more than three months earlier but had been overlooked in that desk drawer until she discovered it — five days after Mitchell had died of a heart attack caused by starvation while in jail.

Last week, I posted a blog that questioned why three Virginia agencies responsible for investigating the Mitchell tragedy hadn’t made public their investigations. The DBHDS released copies of its 29-page report, minus the identities of the employees who investigators questioned, without comment based on separate Freedom of Information requests filed by Sarah Kleiner, an investigative reporter at Richmond Times Dispatch, and by me.

When called by reporters for comment, I said that I was “furious and outraged” by the report. “Jamycheal Mitchell was lost in plain sight because of incompetency and indifference. This kid died because no one in that jail and no state mental health official did anything to help him. Shame on them. Imagine if he was your son. Now there will be lots of finger-pointing and lawyering up, but no real changes. That’s been our sad history in Virginia. This is because officials will blame the victim, as they did in the Natasha McKenna case, and legislators will not put any more money into mental health services.”

What did the internal investigation reveal?

On May 21, 2015, a judge signed a Competency Restoration Order, that was supposed to be mailed to Eastern State Hospital, alerting it that Mitchell needed to be admitted into that hospital. Investigators could find no record of that order ever being sent to the hospital. That was the first mistake.

On July 31, 2015, the court discovered that error and successfully faxed that same judge’s order to the hospital where it apparently was tossed into a desk drawer and not entered into the hospital’s record system. It sat there until a clerk discovered it five days after Mitchell was already dead. Another mistake.

But there is more. In earlier FOIA requests that I made, the DBHDS acknowledged that it had hired an employee in January 2014 to work ten to fifteen hours per week inside the Portsmouth jail because the state “was having challenges with the HNNSCB (Hampton Newport News Community Services Board, which delivers health care in the area) not quickly and consistently getting to the jail to triage restoration referrals.”

That means jailed inmates with mental health issues were sitting in cells without being seen promptly and transferred to the state hospital. Now remember, this employee was hired more than a year before Mitchell was found dead so the HNNSCB and the DBHDS were clearly aware that jail boarding had become a problem in Portsmouth.

Yesterday’s report revealed that this employee apparently did not interview Mitchell. Ever. No one from the state did, as far as I can tell from the edited report.

On July 30th, jail officials became so alarmed about Mitchell that he was sent to the emergency room at the Bon Secours Maryview Medical Center. When he arrived, he refused treatment and was returned to the jail. Jail officials asked that an “emergency assessment” be done. The next morning, Mitchell was taken back to court and officials there realized that the judge’s initial order (sent on May 21) had not been received by the hospital. That led to the court faxing an order to the hospital. Meanwhile, the DBHDS employee, who was supposed to check on Mitchell, went to the jail on the morning of July 31st, while Mitchell was in court. She waited for forty minutes and when he hadn’t returned to the jail, she left without seeing him. She later told investigators that because the court had faxed an order to Eastern State, she didn’t feel he fell under her jurisdiction. He was not her responsibility.

The report reveals that the nurses at the jail, who worked for the for-profit company, NAPHCARE, told investigators that all of their statements and information had been sent to the company’s headquarters in Alabama. Because the names of those being interviewed were deleted from the released report, it is impossible to tell if those nurses cooperated with investigators, but it appears that the state did not ask NAPHCARE for any information. Why? The public deserves to know what this private company did and didn’t do inside that jail.

There was one curious statement in the report by someone employed in the jail. That person was quoted as saying that no one realized Mitchell was not eating because “other incarcerated individuals stated that Mr. Mitchell would ask them for their food…(and) Mr. Mitchell’s food trays were empty indicating he was eating.”

I find it incredible that an inmate’s caloric intake would be determined based on his food trays being empty and other inmates saying that he was eating regularly rather than a physical examination. Had one been done, it would have revealed that Mitchell had lost more than 10 percent of his weight — some 36 pounds — and that he was starving himself.

(Often times inmates who are delusional refuse to eat because they believe they are being poisoned. One solution is to deliver pre-packaged food to that inmate, Joanna Walker, a local NAMI leader told me.)

There will be much finger-pointing and hand-wringing now but what really will be done? It is an important question because there are currently more than 7,000 inmates in Virginia’s local and regional jails. DBHDS hospitals have a census of about 1,500, so our jails hold more than our hospitals. That is true in every state. When Mitchell died, there was a waiting list of 34 inmates ahead of him. How long had those inmates been waiting and under what conditions?

The report released yesterday noted that the employees at Eastern State, who were supposed to log in court orders, were behind because of a staff shortage at the hospital. At least two employees, who used to help out, had left the job and no one had been hired to fill those spots. Mitchell’s death is a result of what happens when our state continues to not adequately finance our mental health system. His death also is another reminder that jails are no place for persons who are mentally ill. Mitchell’s death, and the earlier death of Natasha McKenna in Fairfax County, are evidence of that.

Unfortunately, yesterday’s report does not answer the most important question about Mitchell’s death. How is it possible that he was allowed to starve himself to death? The state seems satisfied to let that question go unanswered. There is no mention in the report that the state will demand an explanation from NAPHCARE. That’s wrong!

The last IG to criticize the DBHDS was G. Douglas Bevelacqua who resigned in protest after his boss soft peddled one of his reports after talking privately to DBHDS officials. When I asked Bevelacqua his opinion of yesterday’s DBHDS report, he wrote in an email:

Let’s be clear. It is inexcusable that a mentally ill person should starve to death while incarcerated in a Virginia jail. There is no explanation that will ease the shocking truth that the Hampton Roads Regional Jail in Portsmouth, and the mental health providers from several organizations – including the Department of Behavioral Health and Developmental Services (DBHDS), the H-NN CSB, and NAPHCARE, Inc., — failed to care for Jamycheal Mitchell.

Bevelacqua questioned why his former agency still has not released its investigation seven months after Mitchell’s death.

New legislation in a number of states requires mental health professionals to assess their patients for the potential to commit gun crimes. For instance, New York state law mandates that mental health professionals report anyone who “is likely to engage in conduct that would result in serious harm to self or others” to the state’s Division of Criminal Justice Services, which then alerts local authorities to revoke the person’s firearms license and confiscate his or her weapons. Similarly, a recently passed bill in Tennessee requires mental health professionals to report “threatening patients” to local law enforcement.

Supporters of these types of laws argue that they provide important tools for law enforcement officials to identify potentially violent persons—and understandably so.

US policymakers and the general public look to psychiatry, psychology, neuroscience, and related disciplines as sources of certainty in the face of the often incomprehensible terror and loss that gun violence inevitably produces.

And to be sure, persons with mental illness who have shown violent tendencies should not have access to weapons that could be used to harm themselves or others.

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However, the notion that psychiatric attention might prevent gun crime is more complicated than it might seem. New research undertaken by me and my colleague, Professor Ken MacLeish, warns of the potential pitfalls of such laws if they are unaccompanied by other community-based or antistigma interventions.1 We systematically reviewed the key psychiatry, psychol- ogy, public health, and sociology literature that addressed connections between mental illness and gun violence between 1960 and 2014. We also used our own primary source historical research on violence and mental illness, and American gun culture.2-4

Our review critically addresses 4 central assumptions that underlie many US political and popular associations between gun violence and mental illness:

• That mental illness causes gun violence

• That psychiatric diagnosis can predict gun crime before it happens

• That US mass shootings teach us to fear mentally ill loners

• That because of the complex psychiatric histories of mass shooters, gun control “won’t prevent” another Tucson, Aurora, Newtown, or Navy Yard

Each of these statements is certainly true in particular instances. At the same time, our research shows how these seemingly self-evident assumptions are replete with complicated and at times contradictory assumptions. At the aggregate level, the notion that mental illness causes gun violence stereotypes a diverse population of persons with psychiatric conditions and oversimplifies links between violence and mental illness. Moreover, notions of mental illness that emerge in relation to gun violence frequently reflect larger cultural issues that become obscured when mass shootings come to stand for all gun crime and when “mentally ill” ceases to be a medical designation and becomes a sign of violent threat.

Our research also shows how anxieties about insanity and gun violence are imbued with often unspoken anxieties about race, politics, and the unequal distribution of violence in American society. In the current American landscape, these tensions play out most clearly in differing cultural responses to, for instance, high-profile shootings in places like Newtown (where headlines located pathology in the perpetrator’s brain) and New York City (where news commentators wondered whether murderous actions were motivated by “black politics.”5)

Ultimately, our research challenges psychiatry to think deeply about potentially untenable situations in which mental health practitioners become the persons most empowered to make decisions about gun ownership—and most liable for failures to predict gun violence—if these situations are not accompanied by larger reforms that address the social, structural, and indeed psychological implications of gun violence in the US.

Our findings appear in the February 2015 issue of the American Journal of Public Health.1 By way of a summary, the following 4 assumptions are examined.

Assumption 1: mental illness causes gun violence

The focus on mental illness in the wake of recent mass shootings in the US reflects a decades-long history of psychiatric and legal debates about guns, gun violence, and mental competence. Psychiatric articles in the 1960s deliberated ways to assess whether mental patients were “of sound mind enough” to possess firearms.6 Following the 1999 mass shooting at Columbine High School, psychiatrist Peter Breggin decried the toxic combination of mental illness, guns, and psychotropic medications that contributed to the perpetrators’ actions. After the 2012 shooting at Sandy Hook Elementary School in Newtown, psychiatrist E. Fuller Torrey claimed that “about half of . . . mass killings are being done by people with severe mental illness, mostly schizophrenia, and if they were being treated they would have been preventable.”7